Provider Demographics
NPI:1154564110
Name:HEALTHPARTNERS MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:HEALTHPARTNERS MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DONNELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-873-2905
Mailing Address - Street 1:35294 EAGLE WAY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60678-1352
Mailing Address - Country:US
Mailing Address - Phone:219-879-6531
Mailing Address - Fax:219-872-7869
Practice Address - Street 1:2307 LAPORTE AVE
Practice Address - Street 2:SUITE 8
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-6997
Practice Address - Country:US
Practice Address - Phone:219-476-8855
Practice Address - Fax:219-476-8840
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HEALTHPARTNERS MEDICAL GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-07
Last Update Date:2009-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN5710110005Medicare NSC